Carers, ethics and dementia: a survey and review of the literature.

BACKGROUND: Much has been written on ethical issues in dementia, but usually from the point of view of the various professionals involved. Whilst there has been an increasing amount of interest in the psychosocial problems that face the carers of people with dementia, the ethical nature of some of these problems has largely been ignored. OBJECTIVE: To review the literature on ethical issues in dementia from the perspective of the main, non-professional carers of people with dementia. METHOD: A systematic literature search using Medline, Clinpsych and CINAHL databases between 1982 and 2000. A pilot study of carers. RESULTS: The lay perspective provides both a wide variety of issues and unique approaches. Although in the literature quantitative research answers some questions, it is qualitative research that deepens our understanding of the issues from the perspective of carers. CONCLUSION: It is particularly qualitative research that brings out the ethical issues for carers, which tend to be more varied than the ethical issues raised in the professional literature. Awareness of such issues could inform and shape the support given to carers.     

Morphologic and immunohistochemical observations in granulomatous glomerulonephritis.

Eight renal biopsies of Wegener's granulomatosis and other vasculitic syndromes with periglomerular granulomatous reactions (granulomatous glomerulonephritis) are studied. Controls consist of 57 biopsies of crescentic and focal necrotizing glomerulonephritis (of various diseases, excluding systemic lupus erythematosus). Both groups have in common the morphologic alterations of inflammatory tuft necrosis, fibrin exudation into the urinary space, crescent formation, and breaks of Bowman's capsule. In the study group, the unique feature of glomeruli with surrounding granulomatous reactions was the presence, within the urinary space, of an exudate of fibrin mixed with immune reactants (immunoglobulins and usually complement) in association with gaps of Bowman's capsule. This contrasts with an exudate of fibrin alone in glomeruli of the control group and other glomeruli of the study group. The study group also had a significantly greater incidence of immune deposits in Bowman's capsule (P less than 0.001). Giant cells may result from the interaction of macrophages of the granuloma with Bowman's capsule that is permeated with immune reactants.     

Influence of preformed α-helix and α-helix induction on the activity of cationic antimicrobial peptides

One prominent class of cationic antibacterial peptides comprises the α-helical class, which is unstructured in free solution but folds into an amphipathic α-helix upon insertion into the membranes of target cells. To investigate the importance of α-helicity and its induction on interaction with membranes, a series of peptides was constructed based on a hybrid of moth cecropin (amino acids 1-8) and bee melittin (amino acids 1-18) peptides. The new peptides were predicted to have a high tendency to form α-helices or to have preformed α-helices by virtue of construction of a lactam bridge between glutamate and lysine side-chains at positions i and i+ 4 at various locations along the primary sequence. In two examples where the use of lactam bridge constraints induced and stabilized α-helical structure in benign (aqueous buffer) and/or hydrophobic medium, there was a decrease in antibacterial activity relative to the linear counterparts. Thus the preformation of α-helix in solution was not necessarily beneficial to antimicrobial activity. In the one case where the lactam bridge did result in increased antibacterial activity (lower minimal inhibitory concentration values) it did not increase α-helical content in benign or hydrophobic medium. Broadly speaking, good activity of the peptides against Pseudomonas aeruginosa correlated best (r²= 0.88) with a helican parameter which was calculated as the induction of α-helix in α membrane-mimicking environment divided by the α-helix formation under benign conditions. Interestingly, the activity of the lactam bridge peptide constructs correlated in part with alterations in bacterial outer or cytoplasmic membrane permeability.     

Renal protection by antihypertensive therapy

The attainment of adequate renal protection requires strict blood pressure control and a diminution of proteinuria or microalbuminuria to values as near from normalcy as possible. It has been considered that by getting the first, the second could be attained at the same price. Recent data have confirmed that renal protection in hypertensive patients, diabetics or not, requires combination therapy that has to include an angiotensin converting enzyme inhibitor or an angiotensin receptor blocker. A calcium channel blocker can be added to this without renal compromise. A diuretic will also be needed in most cases. Proteinuria will diminish with this combination in particular if up-titration of the drug blocking the effects of angiotensin II is performed. The control of other associated risk factors is also required, in particular smoking and lipids.     

The differential response of normal and ischaemic Purkinje fibres to clofilium, d-sotalol and bretylium

To determine whether ischaemic tissue is more sensitive than normal tissue to class III anti-arrhythmic agents, we studied the effects of the class III agents clofilium, d-sotalol and bretylium on normal and ischaemic Purkinje fibres one day after ligation of canine left anterior descending coronary artery. In ischaemic Purkinje fibres superfused with normal Tyrode's solution (4mM K+, 2.7mM Ca+2) clofilium produced early afterdepolarisations at 10(-7)M and 10(-6)M, d-sotalol at 10(-5)M to 10(-3)M, and bretylium at 10(-3)M. The early afterdepolarisation response of ischaemic tissue, which in some cases prolonged action potential duration to beyond 10 s, was significantly different from the simple prolongation of action potential duration seen in normal Purkinje fibres at the same concentrations. Clofilium and d-sotalol differentially produced early afterdepolarisations at or very near "anti-arrhythmic" doses. Therefore, class III anti-arrhythmics produced early afterdepolarisations differentially in ischaemic tissue at concentrations which did not produce early afterdepolarisations in normal tissue.     

Emmonsia crescens infection in a British water vole (Arvicola terrestris).

Emmonsia crescens, a dimorphic fungus of the order Onygenales, is primarily a pathogen of lower animals and rarely humans. Inhaled conidia of E. crescens fail to germinate in the lungs, and instead simply enlarge in lung tissue to become giant adiaspores. We present here the case of fatal Emmonsia crescens infection in a wild-caught British water vole (Arvicola terrestris). Histopathological examination of the animal, which died in captivity, revealed a multifocally extensive granulomatous reaction containing oval adiaspores scattered irregularly throughout the lungs. Mycological examination of fungus cultured from lung tissue and PCR amplification and sequencing of rDNA gene fragments of the cultured organism confirmed the diagnosis of massive infection by E. crescens.